Palliative care aims to provide relief of pain and other patient symptoms, such as fatigue, dyspnea, constipation, anxiety, and depression, in order to improve quality of life. Patients in isolated rural settings often lack easy access to palliative care and other specialist services. Yet rural residents are more likely than their urban counterparts to be older; be in poorer overall health; suffer from more chronic or serious illnesses and disabilities; be uninsured or underinsured; and live in poverty. Telehealth is an emerging method of health care delivery that has been found useful and effective in many clinical settings and specialties. Telehealth technologies can bridge geographic distance and increase access to specialist care in rural settings. We propose a cluster randomized clinical trial design to test the effects of a telehealth-enhanced palliative care symptom-management program for 288 cancer patients and 96 providers in rural health care settings. The proposed program will provide services to both patients and providers: Patients will conduct self-assessments and report pain and other symptoms via telehealth. Health care providers will receive telehealth-delivered case consultations that will include case management, evidence-based practice resources, and peer support. Providers and their patients will be randomly assigned to intervention groups, which receive the telehealth- enhanced palliative care symptom-management intervention, or to control groups. Our primary aim is to compare patient self-reports of symptoms and quality of life in the intervention and control groups over 2 months. Aim 2 is to examine, in the intervention and control groups over 2 months, providers' knowledge and attitudes regarding symptoms and perceived competence in treating symptoms. Aim 3 is to evaluate the cost- effectiveness of the telehealth intervention. We will use mixed effects models with patients nested within providers to evaluate the effect of the intervention on study outcomes. Findings from this study will be instrumental in advancing telehealth and improving symptom management and palliative care among underserved rural populations.